Urinary findings

1. Urinary findings ProfDr.Gülçin Kantarcı Yeditepe University, MedicalFaculty NephrologyDepartment

2. Aim & objective • Interpret the relationship between clinical disease and urinary findings.

3.  The major noninvasive diagnostic tool available to the clinician is the urinalysis. Examination of the urine can also provide some information about disease severity

4. ‘ when the patients die their kidneys reach patologist but their urine is belong to us as long as they are alive and tells us important events as a serial story day by day, month by month and year by year. The urine analysis is the most significant part of physical examination for all patients. Thomas Addis 1948

6. Urinalysis Must be done in one hour after voiding • Colour:Pale-dark yellow (amber ) -hemoglobinuria, myoglobinuria -Bburia -Porfobilinojen(melanoma, alkaptonuria) • Turbidity: clearance and transparency • Chyluria( fistulous connection between lymphatic and urinary system) • Pneomaturia (fistulous connection between bowel and urinary tract, emphysematous pyelonephritis) • Odour: Ǿ

7. Red-brown urine colour

9. Relative density • specific gravity(urinometer, normal range1.000 - 1.060, >1040 glucosuria, proteinuria and radiocontrast media) • Refractometry(only one drop urine , Affected by proteinuria and radiocontrast media) • Osmolality (temperature correction is not neccessary) • Dry chemistry (dipsticks)

10. Chemical features • PH • Haemoglobin • Glucose • Proteins • Leucocyte esterase • Nitrites • Ketones • Bilirubin-urobilinogen

11. PH • PH 4.5-8.0 • Dipsticks indicators: Methyl red ve bromothymol blue • False negative results: in the presence of formaldehyde • pH falling below 5.3 and usually below 5.0. A higher value may indicate the presence of one of the forms of renal tubular acidosis. • Infection with any pathogen that produces urease, such as Proteus mirabilis, can result in a urine pH above 7.0 to 7.5.

12. Hematuria • Gross hematuria may be grossly visible (macroscopic hematuria) • microscopic hematuria detectable only on urine examination: commonly defined as the presence of more than 2 RBCs per high power field in a spun urine sediment

14. Hematuria

15. Glucose Normally,Glucose is not detectable in urine glucose oxidase peroxidase Glucose gluconic acid+HO colored product • Sensitive for: 1-20 g/l • Enzymatic: hexokinase

16. Renal glucosuria • an isolated defect but is more commonly observed in association with additional manifestations of proximal dysfunction, including hypophosphatemia, hypouricemia, renal tubular acidosis, and aminoaciduria. • Fanconi syndrome and may result from a variety of disorders, particularly multiple myeloma.

17. proteinuria • >150 mg/day adults • >140 mg/m2 children • Glomerular (GN, DN) • Tubular ( TIN) • Overload (MM) • Benign ( Jogger N)

18. Proteinuria detection -Dipsticks(albumin)-Precipitation methods Quantitative evaluation Turbidimetric • sulphasalisilic acid (detects all proteins in the urine ) • Tricloroacethic acid Dye binding Biuret Folin-Lowry Qualitativeevaluation Electrophoresis Specificproteins Selectivity of Proteinuria the urine should not be tested for protein with the dipstick for at least 24 hours after a contraststudy

19. Protein/Cr • alternative to 24h urinary analysis of spot urine (morning urine preferred) Ginsberg 1983, Schwab 1987,Ruggenenti 1998, K/DOQI 2002

20. Microalbuminuria High urinary albumine concentrations but dipstick negative urine samples • 30-300mg/24h ADA 1994 • Detection in 24h urine sample is gold standart! • albumin/Cr 30-300 micg albumin/mg creatinine may be used. Assaadi 2002 • Positivity:DM, HT, obesity, hypertriglyseridemia, Oral contraceptive use, female gender and senility. Rosa, Palatini 2000, Monster 2001, Jones 2002

21. Leucocyte estherase • A method related to estherase activity of granulocytes. • Sensitive to leucocytes which undergo lysis, high pH or low density may lead to false positive results. • If glucosuria and >5 gr/l proteinuria are present false negative result may be seen.

22. Nitrites • Presence of bacteria in urine lead to convertion of nitrates to nitrites. • Low sensitivity, High specifity • False negativity: Alkalen urine, some subspecies of Pseudomonas, Staf.,Stept. can reductate nitrit. • False positivity: colored urine.

23. Ketone • Dipstick reaction: Acetoacetate and acetone reaction with nitropurcid. • False negativity: Late processed urine sample. • False positivity: phenyl ketone, levodopa, captopril, sulphydrile containing drugs.

24. Urinary sediment • At least 2 h later from last mixion, second urination of morning. • Sample collected from urinary catheter should not be used. • In a normal patient, one high power field may contain 0 to 4 white blood cells and 0 to 2 red blood cells, and one cast may be observed in 10 to 20 low powered fields.

25. The specimen is ideally examined within 30 to 60 minutes of voiding. • The urine should be centrifuged at 3000 rpm for three to five minutes, most of the supernatant poured out, and the pellet resuspended with gentle shaking of the tube

26. Isomorphic non–glomerular erythrocytes Isomorphic non–glomerular erythrocytes Lökosit Leucocytes

27. Isomorphicnon–glomerularerythrocytes

28. Dysmorphic glomerular erythrocytes

29. Neutrophils

30. renal tubular cell

31. cellsfromthedeeplayers of theuroepithelium

32. cellsfromthesuperficiallayers of theuroepithelium

33. lipid droplets

34. Finely granular cast

35. Waxy cast

36. Erythrocyte cast

37. Leukocyte cast

38. Epithelial cast

39. Uric acid crystals

40. calcium oxalate crystals

41. monohydratedcalciumoxalatecrystals

42. Triple phosphate crystal

43. star–like calcium phosphate crystal

44. Hyalen silendir

45. Urinary sediment findings in Kidney Diseases